PEDS Nursing-Exam III

A child diagnosed with tetralogy of fallot becomes upset, crying and thrashing around when a blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first? a) obtain an order for sedation for the child b) assess for an irregular heart rate and rhythm c) explain to the child that it will only hurt for a short time d) place the child in knee-to-chest position - correct answersAnswer: D. the child is experiencing a "tet spell" or hypoxic episode. Therefore the nurse should place the child in a knee-to-chest position. Flexing the legs reduces venous flow of blood from lower extremities and reduces the volume of blood being shunted through the interventricular septal defect and the overriding aorta in the child with tetralogy of fallot. As a result, the blood then entering the systemic circulation has higher oxygen content, and dyspnea is reduced. Flexing the legs also increases vascular resistance and pressure in the left ventricle. An infant often assumes a knee-to-chest position to relieve dyspnea. If this position is ineffective, then the child may need sedative. Once the child is in this position, the nurse may assess for an irregular heart rate and rhythm. Explaining tho the child that it will only hurt for a short time does nothing to alleviate hypoxia. The mother of a child with tetralogy of Fallot asks the nurse why her child has clubbed fingers. The nurse bases the response on the understanding that clubbing is due to which of the following? a) Anemia. b) Peripheral hypoxia. c) Delayed physical growth. d) Destruction of bone marrow. - correct answersAnswer: B